Adolescent Anemia: Clinical Case and Viva QnA

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Clinical Case of Adolescent Anemia

Sarah, a 15-year-old female, presents to her pediatrician with complaints of fatigue, weakness, and occasional dizziness for the past two months. She reports difficulty concentrating in school and has recently quit the track team due to exhaustion. Sarah's mother notes that her daughter has become increasingly pale and irritable.

Medical History:

Menarche at age 12
Heavy menstrual periods lasting 7-8 days
Vegetarian diet for the past year
No known chronic illnesses
No recent illnesses or injuries

Physical Examination:

Weight: 50 kg (10th percentile)
Height: 160 cm (25th percentile)
Blood Pressure: 110/70 mmHg
Pulse: 92 bpm
Pale conjunctiva and nail beds
Slight tachycardia
No hepatosplenomegaly

Laboratory Results:

Hemoglobin: 9.2 g/dL (Normal: 12.0-15.0 g/dL)
Hematocrit: 28% (Normal: 36-46%)
MCV: 75 fL (Normal: 80-96 fL)
Ferritin: 8 ng/mL (Normal: 12-150 ng/mL)
Peripheral blood smear: Microcytic, hypochromic red blood cells

Based on the clinical presentation, physical examination, and laboratory results, Sarah is diagnosed with iron-deficiency anemia. The pediatrician recommends iron supplementation, dietary counseling, and follow-up to monitor her response to treatment.

Clinical Presentations of Adolescent Anemia

Iron-Deficiency Anemia:
- Fatigue and weakness
- Pale skin, conjunctiva, and nail beds
- Shortness of breath with exertion
- Pica (craving for non-food items)
- Spoon-shaped nails (koilonychia)
- Restless leg syndrome
Thalassemia:
- Pallor and jaundice
- Fatigue and exercise intolerance
- Growth retardation
- Hepatosplenomegaly
- Skeletal changes (frontal bossing, maxillary hypertrophy)
Sickle Cell Anemia:
- Recurrent pain crises
- Fatigue and pallor
- Jaundice
- Delayed growth and sexual maturation
- Increased susceptibility to infections
Vitamin B12 Deficiency Anemia:
- Fatigue and weakness
- Pale or jaundiced skin
- Shortness of breath
- Neurological symptoms (tingling or numbness in extremities)
- Mood changes or depression
Folate Deficiency Anemia:
- Fatigue and weakness
- Pale skin
- Irritability
- Smooth, red tongue
- Diarrhea
Aplastic Anemia:
- Fatigue and pallor
- Frequent or prolonged infections
- Easy bruising or bleeding
- Petechiae or purpura
- Shortness of breath with exertion
Hemolytic Anemia:
- Jaundice
- Dark urine
- Fatigue and pallor
- Abdominal pain
- Leg ulcers (in some chronic cases)
Lead Poisoning-Induced Anemia:
- Abdominal pain and constipation
- Irritability and behavioral changes
- Fatigue and weakness
- Cognitive impairment
- Blue-black lines on gums (Burton lines)

Viva Questions and Answers on Adolescent Anemia

Q: What are the most common causes of anemia in adolescents?
A: The most common causes of anemia in adolescents are:
- Iron deficiency (most frequent)
- Thalassemia
- Chronic diseases
- Vitamin B12 or folate deficiency
- Hemolytic anemias (including sickle cell disease)
Iron deficiency is particularly common due to rapid growth, menstrual blood loss in females, and dietary factors.
Q: How does the WHO define anemia in adolescents?
A: The World Health Organization (WHO) defines anemia in adolescents as:
- For non-pregnant females 15 years and above: Hemoglobin < 12.0 g/dL
- For males 15 years and above: Hemoglobin < 13.0 g/dL
These cutoffs are adjusted for altitude and smoking status.
Q: What are the key features of iron deficiency anemia on a complete blood count (CBC)?
A: Key features of iron deficiency anemia on a CBC include:
- Low hemoglobin and hematocrit
- Low mean corpuscular volume (MCV) - microcytic anemia
- Low mean corpuscular hemoglobin (MCH) - hypochromic anemia
- Increased red cell distribution width (RDW)
- Normal or elevated platelet count
Q: How would you differentiate between iron deficiency anemia and thalassemia minor?
A: Differentiation between iron deficiency anemia and thalassemia minor:
- RBC count: Normal or high in thalassemia, low in iron deficiency
- RDW: Elevated in iron deficiency, normal in thalassemia
- Mentzer index (MCV/RBC): < 13 suggests thalassemia, > 13 suggests iron deficiency
- Serum ferritin: Low in iron deficiency, normal or high in thalassemia
- Hemoglobin electrophoresis: Normal in iron deficiency, abnormal in thalassemia
- Response to iron therapy: Improves in iron deficiency, no change in thalassemia
Q: What is the recommended daily iron intake for adolescents?
A: Recommended daily iron intake for adolescents:
- Males 14-18 years: 11 mg/day
- Females 14-18 years: 15 mg/day
- Pregnant adolescents: 27 mg/day
These recommendations are from the Institute of Medicine (US) and may vary slightly in different countries.
Q: How does menstruation affect iron status in adolescent females?
A: Menstruation significantly affects iron status in adolescent females:
- Average menstrual blood loss is 30-40 mL, equivalent to 15-20 mg of iron
- Heavy menstrual bleeding (>80 mL) can lead to negative iron balance
- Irregular or prolonged menses in early adolescence increases risk of iron deficiency
- Combined with growth needs, menstruation makes adolescent females high-risk for iron deficiency
Q: What are the neurological manifestations of vitamin B12 deficiency in adolescents?
A: Neurological manifestations of vitamin B12 deficiency in adolescents include:
- Paresthesias (tingling or numbness) in extremities
- Difficulty with balance and gait
- Cognitive changes (memory problems, confusion)
- Depression or irritability
- Visual disturbances
- In severe cases, subacute combined degeneration of the spinal cord
Q: How does lead poisoning cause anemia?
A: Lead poisoning causes anemia through multiple mechanisms:
- Inhibition of heme synthesis enzymes (particularly δ-aminolevulinic acid dehydratase)
- Interference with iron incorporation into heme
- Increased fragility of red blood cell membranes, leading to hemolysis
- Inhibition of erythropoiesis in bone marrow
This results in a microcytic, hypochromic anemia with basophilic stippling of red blood cells.
Q: What are the main dietary sources of iron, and how does absorption differ between heme and non-heme iron?
A: Main dietary sources of iron and absorption differences:
- Heme iron sources: Red meat, poultry, fish
- Non-heme iron sources: Leafy greens, legumes, fortified cereals
- Heme iron absorption: 15-35% efficient, not significantly affected by other dietary factors
- Non-heme iron absorption: 2-20% efficient, significantly affected by enhancers (vitamin C) and inhibitors (phytates, tannins)
Q: What is the role of hepcidin in iron homeostasis and anemia of chronic disease?
A: Role of hepcidin in iron homeostasis and anemia of chronic disease:
- Hepcidin is the main regulator of systemic iron homeostasis
- It inhibits iron absorption from the intestine and iron release from macrophages
- In chronic inflammation, hepcidin production increases
- Elevated hepcidin leads to functional iron deficiency and anemia of chronic disease
- This mechanism explains the iron-refractory state in many chronic conditions
Q: How does hemoglobin electrophoresis help in diagnosing hemoglobinopathies?
A: Hemoglobin electrophoresis in diagnosing hemoglobinopathies:
- Separates different hemoglobin types based on their electrical charge
- Can identify abnormal hemoglobins (e.g., HbS, HbC, HbE)
- Quantifies proportions of different hemoglobin types
- Helps diagnose thalassemias by showing altered HbA2 or HbF percentages
- Essential for confirming sickle cell disease and trait
Q: What are the indications for intravenous iron therapy in adolescents with iron deficiency anemia?
A: Indications for intravenous iron therapy in adolescents:
- Intolerance to oral iron supplements
- Poor adherence to oral therapy
- Malabsorption syndromes (e.g., celiac disease, inflammatory bowel disease)
- Severe anemia requiring rapid correction
- Chronic kidney disease with concurrent erythropoietin therapy
- Ongoing blood loss exceeding oral iron absorption capacity
Q: How does anemia affect growth and development in adolescents?
A: Effects of anemia on growth and development in adolescents:
- Reduced physical work capacity and exercise tolerance
- Impaired cognitive function and academic performance
- Delayed onset of puberty and impaired sexual maturation
- Compromised immune function, increasing susceptibility to infections
- Potential long-term effects on final adult height
- In severe cases, cardiac complications and growth retardation
Q: What is the approach to diagnosing and managing anemia in a vegetarian or vegan adolescent?
A: Approach to anemia in vegetarian/vegan adolescents:
- Comprehensive dietary history to assess iron, B12, and folate intake
- Complete blood count with indices, ferritin, B12, and folate levels
- Consider testing for celiac disease if iron deficiency persists
- Recommend iron-rich plant sources and vitamin C to enhance absorption
- Discuss iron and B12 supplementation if dietary intake is insufficient
- Educate on combining foods to optimize nutrient absorption
- Regular monitoring of iron status, especially in female athletes
Q: How does glucose-6-phosphate dehydrogenase (G6PD) deficiency present in adolescents?
A: G6PD deficiency presentation in adolescents:
- Often asymptomatic until exposed to oxidative stress
- Acute hemolytic anemia triggered by certain drugs, foods, or infections
- Symptoms during hemolytic episodes: fatigue, jaundice, dark urine
- Chronic hemolysis in severe variants leading to mild baseline anemia
- Increased susceptibility to certain infections
- Neonatal jaundice history in some cases
Q: What are the key differences in the management of iron deficiency anemia between adolescent males and females?
A: Key differences in managing iron deficiency anemia between adolescent males and females:
- Females generally require higher iron intake due to menstrual losses
- Evaluation of menstrual patterns is crucial in females
- Oral contraceptives may be considered for females with heavy menstrual bleeding
- In males, evaluation for occult blood loss (e.g., gastrointestinal) is more pressing
- Sports-related hemolysis may be more common in male athletes
- Females may require longer duration of iron supplementation
Q: How does anemia affect cardiovascular function in adolescents?
A: Effects of anemia on cardiovascular function in adolescents:
- Increased cardiac output to compensate for reduced oxygen-carrying capacity
- Tachycardia and palpitations, especially during exertion
- Systolic flow murmur due to hyperdynamic circulation
- In severe cases, high-output heart failure can occur
- Left ventricular hypertrophy in chronic severe anemia
- Increased risk of atherosclerosis in certain hemolytic anemias (e.g., sickle cell disease)
Q: What are the implications of anemia for adolescent athletes?
A: Implications of anemia for adolescent athletes:
- Reduced exercise capacity and endurance
- Decreased oxygen delivery to muscles, leading to earlier fatigue
- Impaired athletic performance and training adaptation
- Increased risk of sports-related injuries due to fatigue
- Potential for exercise-induced hemolysis in some endurance sports
- Need for careful iron status monitoring, especially in female athletes
- Importance of proper nutrition and iron intake in athletic meal plans
Q: How does chronic kidney disease contribute to anemia in adolescents?
A: Chronic kidney disease (CKD) contributes to anemia in adolescents through:
- Decreased erythropoietin production by the kidneys
- Shortened red blood cell lifespan due to uremic toxins
- Iron deficiency from reduced absorption and increased losses
- Chronic inflammation leading to functional iron deficiency
- Folate and vitamin B12 deficiencies due to dietary restrictions and malabsorption
- Hyperparathyroidism in advanced CKD affecting bone marrow function
Q: What are the psychological impacts of chronic anemia on adolescents?
A: Psychological impacts of chronic anemia on adolescents:
- Fatigue and reduced energy leading to social withdrawal
- Impaired cognitive function affecting academic performance and self-esteem
- Mood changes, including irritability and depression
- Body image issues, especially with visible symptoms like pallor
- Anxiety about health and future implications of chronic illness
- Stress related to medical appointments and treatments
- Potential delays in psychosocial development due to chronic illness
Q: How do you approach the diagnosis and management of aplastic anemia in adolescents?
A: Approach to diagnosis and management of aplastic anemia in adolescents:
- Diagnosis:
  - Complete blood count showing pancytopenia
  - Bone marrow biopsy revealing hypocellularity
  - Exclusion of other causes (e.g., leukemia, myelodysplastic syndromes)
  - Genetic testing for inherited bone marrow failure syndromes
- Management:
  - Supportive care: blood product transfusions, infection prophylaxis
  - Immunosuppressive therapy (e.g., ATG, cyclosporine) for non-severe cases
  - Hematopoietic stem cell transplantation for severe cases or those unresponsive to immunosuppression
  - Growth factor therapy in some cases
  - Regular monitoring for clonal evolution and secondary malignancies
Q: What are the key features of hemolytic anemia in adolescents, and how is it diagnosed?
A: Key features and diagnosis of hemolytic anemia in adolescents:
- Features:
  - Pallor, jaundice, and sometimes splenomegaly
  - Fatigue, shortness of breath, and dark urine
  - Possible family history in hereditary forms
- Diagnosis:
  - Complete blood count showing anemia with increased reticulocyte count
  - Elevated indirect bilirubin and lactate dehydrogenase (LDH)
  - Decreased haptoglobin levels
  - Peripheral blood smear for red cell morphology
  - Direct Coombs test for autoimmune hemolytic anemia
  - Hemoglobin electrophoresis for hemoglobinopathies
  - Enzyme assays (e.g., G6PD) for specific enzymatic deficiencies
Q: How does sickle cell disease affect adolescent growth and development?
A: Effects of sickle cell disease on adolescent growth and development:
- Delayed physical growth and puberty
- Reduced final adult height
- Delayed skeletal maturation
- Impaired cognitive function due to chronic anemia and silent cerebral infarcts
- Increased metabolic demands leading to nutritional deficiencies
- Bone abnormalities, including avascular necrosis of joints
- Psychosocial challenges related to chronic illness and frequent hospitalizations
- Potential impact on academic performance and career planning
Q: What are the current recommendations for universal screening of anemia in adolescents?
A: Current recommendations for universal anemia screening in adolescents:
- US Preventive Services Task Force: No recommendation for or against routine screening in asymptomatic adolescents
- American Academy of Pediatrics:
  - Screen all adolescents once between 11-21 years of age
  - Annual screening for at-risk groups (e.g., females with heavy menses, vegetarians)
- WHO: Recommends screening in areas with high anemia prevalence
- Many countries have national guidelines tailored to their population's needs
- Targeted screening for high-risk groups is generally recommended
Q: How does anemia impact cognitive function and academic performance in adolescents?
A: Impact of anemia on cognitive function and academic performance in adolescents:
- Reduced attention span and concentration
- Impaired memory and learning capabilities
- Slower processing speed and reaction times
- Decreased executive function skills
- Lower academic achievement, particularly in mathematics and writing
- Increased absenteeism due to fatigue and illness
- Potential long-term effects on educational attainment and career prospects
- Improvements in cognitive function often observed with anemia treatment

Adolescent Anemia: Clinical Case and Viva QnA

Clinical Presentations of Adolescent Anemia

Viva Questions and Answers on Adolescent Anemia

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